Scolaris Content Display Scolaris Content Display

Cochrane Database of Systematic Reviews

Rehabilitación cardíaca con ejercicios para pacientes adultos con angina estable

Information

DOI:
https://doi.org/10.1002/14651858.CD012786.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 02 February 2018see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Heart Group

Copyright:
  1. Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Article metrics

Altmetric:

Cited by:

Cited 0 times via Crossref Cited-by Linking

Collapse

Authors

  • Linda Long

    Institute of Health Research, University of Exeter Medical School, Exeter, UK

  • Lindsey Anderson

    Institute of Health Research, University of Exeter Medical School, Exeter, UK

  • Alice M Dewhirst

    Institute of Health Research, University of Exeter Medical School, Exeter, UK

  • Jingzhou He

    Cardiology, Royal Devon & Exeter NHS Foundation Trust Hospital, Exeter, UK

  • Charlene Bridges

    Farr Institute of Health Informatics Research, University College London, London, UK

  • Manish Gandhi

    Cardiology, Royal Devon & Exeter NHS Foundation Trust Hospital, Exeter, UK

  • Rod S Taylor

    Correspondence to: Institute of Health Research, University of Exeter Medical School, Exeter, UK

    [email protected]

Contributions of authors

LL contributed to writing the protocol, undertook the 'Risk of bias' assessment, conducted the GRADE analysis and led the writing of the final review manuscript.

LA led writing of the protocol, undertook study selection and data extraction and contributed to writing the final review manuscript.

AD contributed to writing the protocol and manuscript, undertook study selection, data extraction and 'Risk of bias' assessment, and approved the final review manuscript.

JH provided clinical expertise, assisted in writing the protocol, undertook study selection, data extraction and 'Risk of bias' assessment.

MG contributed to writing the protocol and provided clinical expertise.

RST led the statistical analysis, conducted the GRADE analysis, edited the review and contributed to writing the final review manuscript.

All authors approved the final review.

Sources of support

Internal sources

  • University of Exeter Medical School, UK.

External sources

  • The Cochrane Heart Group US Satellite is supported by intramural support from the Northwestern University Feinberg School of Medicine and the Northwestern University Clinical and Translational Science (NUCATS) Institute (UL1TR000150)., USA.

  • This project was supported by the National Institute for Health Research, via Cochrane Incentive funding to the Heart Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health, UK.

Declarations of interest

LL declares she has no conflicts of interest.

AD declares she has no conflicts of interest.

JH declares he has no conflicts of interest.

LA is an author on a number of other Cochrane reviews on cardiac rehabilitation (CR).

MG declares she has no conflicts of interest.

RST is an author on a number of other Cochrane reviews on CR and is currently the co‐chief investigator on the programme of research with the overarching aims of developing and evaluating a home‐based CR intervention for people with heart failure and their carers (NIHR PGfAR RP‐PG‐0611‐12004).

Acknowledgements

The review authors thank the Cochrane Heart editorial team for their support. The review authors would also like to express their sincere thanks for the professional and timely handling of the review process by Helen Wakeford and Cochrane Fast‐Track team.

Version history

Published

Title

Stage

Authors

Version

2018 Feb 02

Exercise‐based cardiac rehabilitation for adults with stable angina

Review

Linda Long, Lindsey Anderson, Alice M Dewhirst, Jingzhou He, Charlene Bridges, Manish Gandhi, Rod S Taylor

https://doi.org/10.1002/14651858.CD012786.pub2

2017 Sep 25

Exercise‐based cardiac rehabilitation for patients with stable angina

Protocol

Lindsey Anderson, Alice M Dewhirst, Jingzhou He, Manish Gandhi, Rod S Taylor, Linda Long

https://doi.org/10.1002/14651858.CD012786

Differences between protocol and review

In addition to the outcomes stated in the protocol, we took the decision to extract data for one additional outcome measure, adverse events associated with exercise, as we decided that this is an outcome important to patients.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

PRISMA flow diagram of trial selection
Figures and Tables -
Figure 1

PRISMA flow diagram of trial selection

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Exercise versus no exercise for stable angina, Outcome 1 All‐cause mortality.
Figures and Tables -
Analysis 1.1

Comparison 1 Exercise versus no exercise for stable angina, Outcome 1 All‐cause mortality.

Comparison 1 Exercise versus no exercise for stable angina, Outcome 2 Acute myocardial infarction (AMI).
Figures and Tables -
Analysis 1.2

Comparison 1 Exercise versus no exercise for stable angina, Outcome 2 Acute myocardial infarction (AMI).

Comparison 1 Exercise versus no exercise for stable angina, Outcome 3 Revascularisation procedure (CABG or PCI).
Figures and Tables -
Analysis 1.3

Comparison 1 Exercise versus no exercise for stable angina, Outcome 3 Revascularisation procedure (CABG or PCI).

Comparison 1 Exercise versus no exercise for stable angina, Outcome 4 Exercise capacity.
Figures and Tables -
Analysis 1.4

Comparison 1 Exercise versus no exercise for stable angina, Outcome 4 Exercise capacity.

Comparison 1 Exercise versus no exercise for stable angina, Outcome 5 Cardiovascular‐related hospital admissions.
Figures and Tables -
Analysis 1.5

Comparison 1 Exercise versus no exercise for stable angina, Outcome 5 Cardiovascular‐related hospital admissions.

Summary of findings for the main comparison. Exercise‐based cardiac rehabilitation compared to usual care for adults with stable angina

Exercise‐based cardiac rehabilitation (CR) compared to usual care for patients with stable angina

Patient or population: adults with stable angina
Setting: hospital, outpatient clinic, community or home‐based environment
Intervention: exercise‐based cardiac rehabilitation
Comparison: usual care (standard medical care but without any structured training or advice on structured exercise training)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with usual care

Risk with exercise‐based cardiac rehabilitation

All‐cause mortality

Follow‐up: 12 months

Study population

RR 1.01
(0.18 to 5.67)

195
(3 RCTs)

⊕⊝⊝⊝
VERY LOW 1,2,3

We are uncertain about the effect of exercise‐based CR on all‐cause mortality compared to usual care.

20 per 1,000

21 per 1,000
(4 to 116)

Acute myocardial infarction (AMI)

Follow‐up: 12 months

Study population

RR 0.33
(0.07 to 1.63)

254
(3 RCTs)

⊕⊝⊝⊝
VERY LOW 2,3,5

We are uncertain about the effect of exercise‐based CR on AMI compared to usual care.

39 per 1,000

13 per 1,000
(3 to 64)

Exercise capacity

(assessed using a variety of outcomes including VO2 max and duration of exercise)

Follow‐up: range 6 to 12 months

The mean exercise capacity in the intervention groups was 0.45 standard deviations higher
(0.2 higher to 0.7 higher)

267
(5 RCTs)

⊕⊕⊝⊝
LOW 4,6

Using Cohen's rule of thumb a SMD of 0.2 represents a small effect, 0.5 a moderate effect and 0.8 a large effect between groups (Cohen 1988).

Exercise‐based CR may slightly improve exercise capacity compared to usual care.

Cardiovascular‐related hospital admissions
(assessed with: combined clinical endpoint (cardiac death, stroke, CABG, PCI, AMI, worsening angina with objective evidence resulting in hospitalisation))

Follow‐up: 12 months

Study population

RR 0.14

(0.02 to 1.1)

101
(1 RCT)

⊕⊝⊝⊝
VERY LOW 2,7,9

We are uncertain about the effect of exercise‐based CR on cardiovascular‐related hospital admissions compared to usual care.

140 per 1000

20 per 1000 (2 to 154)

Health‐related quality of life (assessed with: Seattle Angina Questionnaire and The MacNew Questionnaire)
Follow‐up: range 6 weeks to 6 months

One study showed improvement in emotional score at 6‐week follow up, and benefits in angina frequency and social HRQL score at 6 months follow‐up.

Not estimable

94

(1 RCT)

⊕⊝⊝⊝
VERY LOW 8,9

We are uncertain about the effect of exercise‐based CR on quality of life compared to usual care.

Return to work

No studies were found that looked at return to work.

Adverse events (e.g. skeletomuscular injury)

Follow‐up: 12 months

Only one study looked at adverse events and reported that there were no adverse events during the exercise‐based CR.

Not estimable

101

(1 RCT)

⊕⊝⊝⊝
VERY LOW 2,7,9

We are uncertain about the effect of exercise‐based CR on adverse events compared to usual care.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

AMI: acute myocardial infarction; CABG: coronary artery bypass graft; CI: confidence interval; CR: cardiac rehabilitation; HRQL: health‐related quality of life; PCI: percutaneous coronary intervention;RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Some concerns with random sequence generation, allocation concealment, blinding of outcome assessment and selective reporting; bias likely, therefore quality of evidence downgraded by one level

2 Some concern with applicability to review question as participants in all studies were limited to middle‐aged men, therefore quality of evidence downgraded by one level

3 Imprecise due to small number of participants (less than 300) and confidence intervals including potential for important harm or benefit as 95% CI crosses RR of 0.75 and 1.25, therefore quality of evidence downgraded by two levels

4 Some concerns with random sequence generation, allocation concealment, blinding of outcome assessment, selective reporting and unbalanced groups at baseline; bias likely, therefore quality of evidence downgraded by one level

5 Some concern with random sequence generation, allocation concealment, blinding of outcome assessment, high loss to follow‐up, selective reporting and unbalanced groups at baseline; serious bias likely, therefore quality of evidence downgraded by two levels

6 Imprecise due to small number of participants (less than 300) therefore quality of evidence downgraded by one level

7 Some concerns with random sequence generation, allocation concealment and selective reporting; bias likely, therefore quality of evidence downgraded by one level

8 Some concerns with blinding of outcome assessment, selective reporting and groups not receiving comparable care; bias likely, therefore quality of evidence downgraded by one level

9 Imprecise due to very small number of participants therefore quality of evidence downgraded by two levels

Figures and Tables -
Summary of findings for the main comparison. Exercise‐based cardiac rehabilitation compared to usual care for adults with stable angina
Comparison 1. Exercise versus no exercise for stable angina

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 All‐cause mortality Show forest plot

3

195

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.18, 5.67]

2 Acute myocardial infarction (AMI) Show forest plot

3

254

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.07, 1.63]

3 Revascularisation procedure (CABG or PCI) Show forest plot

3

256

Risk Ratio (M‐H, Fixed, 95% CI)

0.27 [0.11, 0.64]

4 Exercise capacity Show forest plot

5

267

Std. Mean Difference (IV, Fixed, 95% CI)

0.45 [0.20, 0.70]

5 Cardiovascular‐related hospital admissions Show forest plot

1

101

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.02, 1.10]

Figures and Tables -
Comparison 1. Exercise versus no exercise for stable angina